Comparison of Home-Blenderized Formula and Commercial Enteral Formulas for Gastrostomy Tube-Fed Children: A Retrospective, Prospective Cohort Study.

Background Blenderized gastrostomy tube feedings (BGTFs) consist of pureed table foods and liquids that are administered as enteral tube feedings. Compared to commercial enteral formulas (CEFs), BGTF has been shown to have fewer side effects. Despite these results, apprehensions have been raised about microbial contamination, nutritional deficiencies or surplus, risk of gastrostomy tube (GT) blockages, and lack of consistency in clinical outcomes. The goal of this retrospective, prospective, 18-month-long study is to report the clinical and nutritional outcomes of GT-dependent pediatric patients who attended a multidisciplinary feeding clinic. Methodology After Institutional Review Board (IRB) approval and consent were obtained, 25 children who were receiving tube feeding via G were enrolled in a retrospective, prospective, observational, cohort study from August 2019 to February 2021. A multidisciplinary team was formed, and multivariate logistic regression was performed comparing subjects on BGTF versus CEF, per os diet versus nil per os, CEF versus homemade blenderized tube feeding (HBTF) versus blenderized tube feeding (BTF), and how they compared at the beginning and end of the study. Results The mean age of the patients was 4.4 years (SD ±2.2). Gastroesophageal reflux disease (GERD) and short bowel syndrome (SBS) were the most common comorbid gastrointestinal (GI) conditions. Of the 25 patients enrolled in the study, seven were initially on BGTF, while 14 ended the study on BGTF. There were no statistically significant differences in malnutrition status, feeding intolerance, emergency room visits, hospitalizations, and GT blockages between all different comparison groups when comparing between the CEF versus HBTF versus commercial blenderized tube feeding (CBTF) groups. Of the patients who were in the BGTF group, there was a resolution of vitamin A deficiency, vitamin D deficiency, and anemia (n = 1). In total, two patients had resolved vitamin deficiencies, namely, vitamins A and D. Conclusions When comparing BGTF and CEF, there was no statistically significant difference in outcomes. This study suggests that BGTF is at least equivalent to CEF in clinical outcomes, meaning BGTF should be considered standard nutrition for GT-dependent patients.

A retrospective review of the 5-year nutritional and clinical outcomes in pediatric patients undergoing intestinal rehabilitation.

BACKGROUND: The mainstay of modern medical therapy for intestinal failure (IF) is parenteral nutrition (PN). The Intestinal Rehabilitation Program (IRP) goal is enhancing nutritional outcomes for patients receiving total parenteral nutrition (TPN), optimizing/transitioning patients from TPN to enteral nutrition (EN), achieving enteral autonomy, monitoring growth and development. The objective of this study is to describe nutritional and clinical outcomes for children undergoing intestinal rehabilitation during 5 years of the program. METHODS: Retrospective chart review for children from birth to <18 years old with IF who were on TPN from July 2015 to Dec 2020 or to the endpoint of the study when they either weaned from TPN during the 5 year period or continued TPN by Dec 2020 and participated at our IRP. RESULTS: The mean age of the cohort was 2.4 years (±4.22), 53% male. The 3 most common diagnosis were necrotizing enterocolitis (28%), gastroschisis (14%) and intestinal atresia (14%). Nutritional data including days/hours per week on TPN, glucose infusion rate, amino acids, total EN calories, % of total nutrition received from TPN and EN per day all showed statistically significant differences. Our program showed 0% intestinal failure associated liver disease (IFALD), 0% mortality, 100% survival, 41% patients were weaned from TPN (13/32) with mean of 39 months (±32). CONCLUSION: Early referral to a center that can offer IRP, such as ours can lead to tremendous positive clinical outcomes and help patients with intestinal failure avoid transplant as shown in our study.

A Multidisciplinary Approach and Development of an Algorithm for Timely Repair of Central Venous Access in Pediatric Patients.

BACKGROUND: Central venous catheters (CVCs) carry a risk for many complications. This can lead to numerous and prolonged hospitalizations for patients undergoing intravenous nutrition. The aim was to create a standardized protocol for the medical facility to expedite the repair process as well as implement a broadened educational effort for the care of CVCs. METHOD: A retrospective chart review was completed for 365 catheter days before implementation. Two protocols were then created in collaboration with the multidisciplinary team. Prospective chart data were subsequently collected 365 catheter days post-implementation. RESULT: Pre-implementation (32 encounters), 100% of compromised CVCs required admission. Post-implementation (21 encounters), only 48% of compromised CVCs required admission accompanied by an overall reduction in the number of compromised catheters that presented to the hospital. The average hospital length of stay pre-protocol initiation decreased from 7.2 to 1.8 days post-protocol initiation. The implementation of our algorithm also lead to a decrease in the average cost of compromised CVC repair inpatient ($2741) vs repair in the emergency department ($34,436). CONCLUSION: This study demonstrates that working with a multidisciplinary team utilizing a standardized protocol improved the quality of patient care by decreasing hospital admissions for compromised CVCs. The authors also conclude that the expedited repair of CVCs can help alleviate health care costs for both families and the hospital system.

Clinical Data and Health Outcomes for HIV-Positive Patients Diagnosed With COVID-19.

Introduction As we care for patients during the coronavirus pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is important to learn and analyze the health outcomes for HIV-positive patients who have been infected with COVID-19. The clinical course and outcome of COVID-19 among patients with HIV-1 infection are still unknown and novel. Methods This is a retrospective cohort study of 34 HIV-positive patients who are diagnosed with COVID-19. The following basic demographic, clinical, and laboratory test information were collected for each patient: age, race/ethnicity, gender, CD4/viral load count before and after COVID-19 diagnosis, clinical symptoms, hospitalizations, antiretroviral medications, and comorbidities. These data were collected from the electronic health record (EHR) and recorded in the study database. Results The mean (interquartile range (IQR)) HIV viral load (RNA PCR) after COVID-19 infection was 37,170 (<20-167) copies/mL compared to 25,730 (<20-100) copies/mL before COVID-19 infection. The mean (IQR) CD4+ lymphocyte count prior to and after COVID-19 infection was 583 (101-1139) and 477 (167-821) cells/mm3, respectively. Hypertension (n = 20) was the most prevalent comorbidity found in the cohort of HIV-positive patients. Patients with HIV RNA < 20 copies/mL prior to and after COVID-19 infection were 27 (79.3%) and 17 (73.7%), respectively. Conclusion As the pandemic situation keeps on evolving, there will be new findings on how people living with HIV might be affected by SARS-CoV-2. Our findings highlight the importance of larger sample size studies to better understand the management of HIV-positive patients in a pandemic situation.

Is type of practice setting associated with physician's cultural competency training? Analysis from the National Ambulatory Medical Care Survey.

This study examined whether type of physician practice settings was associated with cultural competency training for newly hired physicians. We used data from the 2016 National Ambulatory Medical Care Survey Supplement on Culturally and Linguistically Appropriate Services for Office-based Physician Survey. The survey contains a sample of 397 office-based physician responses completed during the period from August to December 2016 (weighted n = 293306). The outcome variable was whether cultural competency training was required for newly hired physicians. The primary predictor variable was type of physician practice settings. We used logistic regression to analyze the association between physician practice settings and cultural competency training for newly hired physicians adjusting for covariates. About 71% physicians belonged to solo or group practice settings. Among these, only 10.4% required cultural competency training for newly hired physicians. Among other practice settings, 34.8% required the training. Results from logistic regression showed that newly hired physicians in solo or group practices (adjusted odds ratio: 0.22; 95% confidence interval: 0.11-0.44) were less likely to have cultural competency training compared to those in other settings. Practice settings are associated with cultural competency training. Cultural competency training across all practice settings may contribute toward improving patient-physician communication, reducing health disparities, and increasing patient satisfaction.

Reversal of Intestinal Failure-Associated Liver Disease in an Infant Treated With Mixed Lipid Emulsion and Multidisciplinary Intestinal Rehabilitation Program.

Intestinal failure-associated liver disease (IFALD) can lead to increased morbidity and mortality in patients with intestinal failure (IF). We report the case of a premature infant born at 25 weeks' gestation at a neighboring facility that developed surgical necrotizing enterocolitis and secondary IF with 6 cm of small bowel remaining measured from the ligament of treitz with jejunocolonic anastomosis. The patient's course was complicated by IFALD and transferred to our intestinal rehabilitation program at 3 months of age. He was treated with SMOF lipid in reduced lipid dosages to prevent and treat IFALD, including cycling of parenteral nutrition, monitoring of the glucose infusion rate, and adjusting the micronutrient, trace elements, and aggressive enteral feeding. Omegaven had not yet been approved during the time of this case presentation. During the course of his treatment, he experienced normalization of his liver profile tests and progressed toward enteral autonomy.

Urgent Care Center and Emergency Department Utilization for Non-Emergent Health Conditions: Analysis of Managed Care Beneficiaries.

The objective was to identify predictors of utilization for urgent care centers (UCCs), emergency departments (EDs), or for both services for non-emergent health conditions among beneficiaries from a managed care organization (MCO) who resided within a 10-mile radius of UCCs. A cross-sectional design was used to analyze 2016 administrative claims data from an MCO that contracted with a UCC with 12 locations (n = 20,107). Outcome variables were number of visits to UCC, ED, or both. The MCO used the New York University ED algorithm to identify non-emergent health conditions. The Behavioral Model of Health Care Utilization was used as a conceptual framework to identify predictors in the model; age, sex, race/ethnicity, distance to UCC from residence, type of insurance, primary care physician visits, inpatient admissions, chronic conditions, morbid obesity, and smoking behavior. Generalized linear models were used to analyze the association between outcomes and predictors. About 22.7% were UCC users, 66.8% were ED users, and 10.5% used both. African Americans (incident rate ratio [IRR] = 0.95; 95% confidence interval [CI]: 0.91-0.98] were less likely to use UCCs and more likely to use the ED (IRR = 1.10; 95% CI: 1.07-1.13). Beneficiaries with multiple chronic conditions were more likely to use the ED than UCCs. Distance was not a predictor of UCC or ED usage. Utilization of UCC was low for non-emergent health conditions. African Americans and individuals with multiple chronic conditions preferred the ED to UCC for non-emergent health conditions. This study implies that MCO beneficiaries, especially the African American population, need to be informed about UCC locations and services provided.